How Do We Best Achieve Smoking Cessation, Ideal Body Weight, and Weight Loss as Modifiable Risk Factors

I. Adverse Health Habits: What every physician needs to know.

What do we know about how patients develop their health habits and how to change them? Why should I counsel patients about health behavior?

There are so many possible health habits for which to provide counseling. While they are all important, three areas provide the largest possible impact on your patients’ health. Smoking, poor diet, and physical inactivity are the three most important health behaviors on which to counsel patients. These three health behaviors contribute to the four leading chronic diseases (cancer, heart disease, and stroke; type 2 diabetes, and pulmonary diseases), which in turn cause 50% of mortality worldwide.

Health habits are learned behaviors. People tend to adopt health habits similar to those of their families and close friends. We are also influenced by our environment, which acts as a cue to behave in certain ways. For example, being in the presence of smokers increases our likelihood of smoking, and driving by fast food restaurants increases the chances that we will consume fast food.

While it may not make sense to persist in behavior that has a negative impact on one’s health, there are usually benefits that people get out of a “bad habit”, such as smoking cigarettes or overeating to manage stress. Poor health habits may “work” in some ways to reduce stress, but the improvements are temporary and have additional negative impacts.

In the same way that people learn poor health habits, they can learn healthy habits.

Research supports some general recommendations about behavior change, and these concepts relate to most health habits.

Research shows that telling a patient whatto do (increasing their knowledge about the benefits of making a lifestyle change) is necessary but insufficient for behavior change. Patients need to know how to change and what it is that they should do (how to reduce calories and how much physical activity is OK for them to do), but this alone will not lead to behavior change.

Using behavior change strategies (such as self-monitoring, setting realistic goals, problem solving, and social support) is related to the successful adoption of new health behaviors. Good interventions must include these components to have the best change of helping patients change their lifestyle.

Of all the strategies, self-monitoring or routinely keeping track of one’s health behavior is the most predictive of successful change, so if you are going to recommend one thing to your patients, recommend that they keep track of cigarettes/urges, amount of physical activity, or what they eat (depending on the behavior change goal).

There is a dose response relationship between the amount of behavioral change realized and the “dose” of behavioral intervention they receive. Generally, longer more intensive behavioral interventions result in greater behavioral change. That said, the brief advice providers give to their patients in the very little time they have with them can positively impact their patients’ success. These brief interventions can “nudge” patients in the right direction and increase their likelihood of success.

A. History: Prevalence:

Smoking

The smoking prevalence rate in the U.S. decreased drastically and steadily throughout the 1970s and 1980s, but it has stalled in recent years, consistently hovering around 20% of adults (18+ years) nationwide. Smoking prevalence varies widely across different segments of the population, with increased risk among individuals with certain demographic profiles.

In particular, individuals with mental health disorders face a disproportionately higher risk of smoking and experience greater difficulty quitting. Other demographics associated with higher smoking rates include: male sex, race/ethnicity (e.g., African Americans), fewer years of education, and lower socioeconomic status. In addition, environmental and policy factors, such as indoor/outdoor smoking bans, media exposure, state/region of residence, and cigarette taxes, play an important role in the risk of smoking.

Physical activity

Insufficient physical activity is en route to surpassing smoking as the biggest public health problem of the 21st Century. A mere 30% of the U.S. population reportedly engages in regular leisure time physical activity, and fewer than half meet public health guidelines for recommended levels of physical activity.

A separate but closely related problem is sedentary behavior, which refers to the amount of time spent engaging in sedentary activities outside of time spend engaging in physical activity. Recent evidence suggests that these two behaviors (i.e., physical activity and sedentary behavior) are independent risk factors for cardiovascular disease.

Individuals with certain demographic characteristics, including female sex, minority race/ethnicity, fewer years of education, and lower socioeconomic status, are more likely to report insufficient physical activity and/or excessive sedentary behavior. Furthermore, environmental and policy factors, such as access to safe and convenient places to be physically active, the built environment (e.g., mixed land use, sidewalks), and workplace policies allowing time for physical activity, play important roles in the risks of physical activity and sedentary behavior.

Overweight/obesity

Current statistics reveal that approximately two thirds of the U.S. adult population is overweight or obese according to the standard body mass index (BMI) cutoffs (underweight <18.5, healthy weight = 18.5 to 24.9, overweight = 25 to 29.9, obese >=30, super obese >=40). Perhaps even more alarming is the fact that within the total overweight/obese population, the obese (35.7%) and super obese (6.3%) categories represent even higher percentages of the population than the overweight (33%) category and are also growing at the fastest rates.

On the other hand, after a dramatic rise in overweight/obesity incidence during the late 20th and early 21st centuries, the overall prevalence of adults within either of these categories appears to have stabilized. Certain demographic characteristics, including minority race/ethnicity, fewer years of education, and lower socioeconomic status, are associated with greater risk of overweight/obesity.

The prevalence of overweight is higher among men (38.4%) than women (29.7%), and the prevalence of extreme obesity is higher among women (8.1%) than men (4.4%), but the prevalence of obesity (35% to 36%) is similar across sexes. Certain environmental and policy factors, such as greater prevalence of fast food restaurants, lower availability of grocery stores and fresh produce, relatively higher price of healthy vs. unhealthy foods, and state/region of residence (e.g., states in the Southern and Midwest regions), are associated with increased risk of overweight/obesity.

D. Physical Examination Findings.

N/A

E. What diagnostic tests should be performed?

How to assess smoking status, physical activity, and overweight/obesity

Smoking: Many clinical settings include smoking status as a vital sign. To assist you in giving appropriate recommendations to your patients, you should first assess patients’ current smoking status:

I never smoked

I used to smoke but quit and have not smoked in the past 30 days

I have smoke on XX of the past 30 days.

If yes, on the days that you smoked, how many cigarettes did you smoke per day?

Or ask a single question, “Have you smoked in the past 30 days?” (Yes/No)

Physical activity: Physical activity assessments should ascertain whether or not patients are meeting the national physical activity guidelines (created and endorsed by the American Heart Association [AHA] and American College of Sports Medicine [ACSM]). Public health guidelines recommend >=150 min/wk of moderate intensity aerobic activity. Broken down more specifically, these guidelines suggest accumulating 30 minutes of moderate intensity physical activity (in bouts of at least 10 minutes) on at least 5 days/wk.

Ask:

On how many days per week do you accumulate 30 or more minutes of moderate intensity physical activity (like brisk walking where you are somewhat out of breath but can still talk)? You can count physical activity bouts that last 10 minutes or more.

On how many of the past 7 days did you:

(Note: Aerobic activity goal can be met with either A, B, or a combination of both)

(A) Do moderate intensity physical activity (causing a noticeable increase in breathing but where you can still talk) for at least 30 minutes: (0 to 7) Goal is 5 or more.

(B) Do vigorous intensity aerobic exercise (causing greater increases in breathing or heart rate, such as jogging) for at least 20 minutes: (0 to 7) Goal is 3 or more.

(D) Do stretching or flexibility exercises engaging all parts of your body: (0 to 7) Goal is 2 to 3.

Weight: It is ideal to measure weight rather than getting self-reported weight. Since most patients are weighed at check-ins for clinical appointments, this is generally not a problem. However, if it is not possible to weigh patients, ask for a self-report of their weight the last time they weighed themselves.

Body mass index ([BMI] weight in kilograms per height in meters squared) is used to estimate body fat and categorize overweight status. It may overestimate body fat in athletes or those with muscular build and may underestimate body fat in the elderly or those who have muscle wasting/loss. However, it is generally a reliable and simple estimate to use.

Link to BMI calculator:

http://nhlbisupport.com/bmi/

BMI categories:

Underweight: <18.5

Normal weight: 18.5-24.9

Overweight: 25-29.9

Obesity: 30 or greater

We recommend using body weight (maintenance or reduction) as the goal for patients because they can easily measure it at home and understand the concept without much explanation.

Immediate management.

Health behavior change adoption

Smoking

Research shows that the majority of smokers express a desire to quit at some point. In addition, most smokers make multiple attempts at quitting before they successfully quit.

Physician advice to quit along with a referral to additional methods is an effective strategy to help patients obtain access to resources that will help them quit and further increases the odds of cessation attempts and successful cessation. Evidence suggests that, when given the choice, smokers who choose to attempt quitting by gradually reducing their smoking rate (i.e., number of cigarettes per day) are as likely to succeed as those who attempt quitting by eliminating all cigarettes at once. Thus encouraging smokers to choose which of these two strategies they prefer may increase their odds of successful cessation.

Following is a brief summary of smoking cessation assistance strategies by current research:

Brief physician advice. Brief assessment of current smoking status and (if applicable) advice to quit smoking during health care visits significantly increases cessation attempts and success among smokers. A meta-analysis of randomized controlled trials comparing brief advice to no advice revealed a relative risk (RP) of 1.66 (95% CI: 1.42-1.94) at 6 months postintervention. The increased chance of cessation (compared to no advice) at 6 months is even higher when physician advice interventions include at least one follow-up visit (RP = 1.84, 95% CI: 1.60-2.13). The “5 A’s” (Ask, Advise, Assess, Assist, and Arrange) approach is recommended as a guideline for physicians to use with their smoking patients. Research suggests that physicians often perform the first two steps (Ask, Advise) but fail to follow through with the final three (Assess, Assist, Arrange). Because additional cessation assistance increases quit attempts and cessation success, physicians should focus more on the “Assist” and “Arrange” steps during the limited time they have with patients or refer them to a quit line for additional counseling.

Telephone Quitlines. In collaboration with all U.S. states, the Department of Health & Human Services (HHS) offers a free cessation service for smokers: telephone quitlines. Multiple languages are currently available, and some states provide free nicotine replacement therapy to smokers who desire to use this additional aid. All smokers can call the same toll-free number (1-800-QUIT-NOW) to immediately connect with an experienced cessation counselor; to receive a personalized quit plan; and self-help materials, social support, and coping strategies to help them cope with cravings, and the latest information about cessation medications. They can also connect callers with cessation services and other resources offered near their residence. Although variable depending on treatment engagement and offered services used by callers, a meta-analysis demonstrated that quitlines increase the odds of cessation by approximately 1.6 (95% CI: 1.4-1.8). Referral to a quitline requires minimal additional time during a health care visit; physicians can merely provide the quitline number in writing and recommend that their patients call for additional smoking cessation assistance. Visit the website listed in the resources section and they will send you free referral cards to distribute to patients.

Nicotine replacement therapy. Nicotine replacement therapy (NRT) is the most frequently used cessation assistance method, and evidence supporting its effectiveness is strong. NRT is currently available in a variety of forms, including the nicotine patch, gum, lozenge, inhaler, and nasal spray, and they all appear to be comparably effective, increasing the odds of successful cessation by 50% to 70%. A meta-analysis revealed a relative risk of 1.58 (95% CI: 1.50-1.66) among RCTs comparing any type of NRT to no treatment control groups. Additional support (e.g., cessation counseling) can increase effectiveness of NRT by approximately 10% to 25%. Although NRT can be purchased over-the-counter, smokers may be more likely to use it if they are given a prescription for it. Similarly, NRT is designed to replace nicotine intake, matching the dose of NRT with individuals’ current smoking rate is recommended. Labels on NRT boxes provide dosage and usage guidelines.

Other pharmacotherapies. Aside from NRT, other medications are often used to assist with cessation. Unlike NRT, these medications require a prescription. Bupropion (Wellbutrin) and varenicline (Chantix) are the most frequently prescribed non-NRT medications for smoking cessation. Evidence suggests that their effectiveness is comparable to that of NRT. Insurance coverage for these medications varies widely, and their relatively high cost (compared to NRT) can be a deterrent for individuals without insurance. On the other hand, some smokers prefer these alternative medications over NRT. Thus, providing individuals with the option to choose between NRT and these alternative pharmacotherapies may increase their treatment compliance and, in effect, cessation success.

Physical activity

Although the majority of adults aspire to be more physically active, most do not meet the current physical activity guidelines for general health. Individuals report a variety of reasons for their insufficient physical activity levels, including lack of time, motivation, social support, knowledge, and access to safe and convenient places to be active, among others. Behavioral interventions are designed to help individuals increase and maintain their activity levels.

Physical activity counseling should include recommendations for aerobic physical activity (e.g., walking, bicycling, swimming), strengthening (e.g., weight machines, free weights, bodyweight exercises), and flexibility/stretching (e.g., yoga, general stretching) exercises, allowing individuals to choose their preferred types of exercise. At minimum, public health guidelines (endorsed by AHA and ACSM) recommend accumulated weekly aerobic activity (>=150 minutes), strength training incorporating exercises for all major muscles groups (>=2 sessions/week), and flexibility/stretching (>=2 sessions/week incorporating a variety of full-body movements). However, programs should emphasize that some exercise is better than none, so individuals should be encouraged to be as physically active as possible, even if they are not motivated to or physically capable of completing the recommended amount of physical activity for general health.

Sedentary behavior

Sedentary behavior is independent of physical activity and sedentary time is related to health problems. The amount of time patients spend sitting on a daily basis should also be assessed and (if applicable) reduced.

The national recommendation is to spend no more than 2 hours of sedentary time (not including work/school). Many of our patients are sedentary for most of the day. However, because accumulating multiple, shorter bouts of physical activity improves health as much as engaging in sustained bouts of activity, encouraging patients to break up their sedentary time with short bouts of activity may address both problems (i.e., insufficient physical activity and too much sedentary behavior). Even asking patients to break up long periods of sitting with several minutes of standing is a meaningful improvement.

Do physical activity interventions work?

In a recent meta-analysis of RCTs, physical activity and dietary interventions produce small to moderate effect sizes. However, even small changes in PA can result in important improvements in health outcomes. Recent research has demonstrated that encouraging individuals to focus more on the immediate rewards of physical activity (e.g., increased energy, enjoyment, mood/affect improvement) than on the long-term effects (e.g., reduced morbidity and mortality, longer lifespan) may help increase their motivation for daily physical activity.

Evidence supports the efficacy of physical activity interventions that incorporate multiple behavioral adherence strategies, especially self-monitoring, social support, and goal-setting. Thus physicians should encourage patients who are insufficiently physically active to consider increasing their activity level either on their own or by joining a community resource (e.g., the YMCA), whether it be offered in-person or via an alternative delivery channel (e.g., Internet, telephone, mobile application), as evidence supporting each of these methods is comparable.

Referring patients to existing, effective physical activity promotion programs may help them increase and maintain physical activity and/or reduce sedentary behavior. Programs that incorporate a combination of the following behavioral strategies may be particularly helpful for patients:

Goal-setting with regular check-ins, focusing on small incremental changes in physical activity (e.g., increasing number of minutes or steps per day by 10% at a time)

Social support (e.g., workout partner, family/friend support)

Focus on the immediate rewards of physical activity (e.g., fun/enjoyment, increased energy levels, mood/affect improvement) instead of or in addition to the long-term health benefits

Weight loss (caloric restriction)

Although some of overweight/obese individuals are content with their weight status, research shows that most desire to lose weight. Therefore, a majority of overweight/obese patients are open to weight loss advice and treatment. Individuals who are not motivated to lose weight should be encouraged to adopt a weight maintenance plan, including both diet modification/monitoring and regular physical activity. Weight loss can seem overwhelming to those with particularly excessive amounts of weight. Research shows that losing 5% to 10% of body weight provides significant health benefits (e.g., reduced blood pressure, glycemic load), so patients should be encouraged to lose even relatively small amounts of weight. This is an easier goal to achieve and will increase the patient’s level of confidence that they can succeed. Caloric restriction is more important for initial weight loss and increased physical activity is more important for weight loss maintenance.

Weight loss medications are not particularly effective, and they typically have numerous unwanted side effects. Surgical option, which had previously been reserved for only the most morbidly obese individuals or those with multiple weight-related comorbid health problems, are becoming increasingly available. Surgical options are often effective, but their high costs, nonuniversal coverage by insurance, recovery times, and possible risks are significant barriers. Moreover, although weight loss medications and/or surgery can speed up or enhance weight loss, diet modifications are absolutely necessary for weight loss and maintenance. Indeed, the immediate and long-term caloric intake allowances for most types of weight loss surgeries are drastically lower than those recommended during safe and effective weight loss programs, making them potentially even more difficult for patients to follow and, in effect, ultimately leading to weight regain (assuming initial weight loss was attained).

Assuming no weight loss medications or surgical procedures have been used, physicians should advise their patients to reduce their daily caloric intake to achieve an overall negative energy balance of approximately 500 kilocalories per day to result in weight loss of approximately 1 pound per week. Losing 1 to 2 pounds per week is related to longer weight loss maintenance. Reducing caloric intake can be achieved in various ways. Simplifying the options for patients by recommending the following three strategies may help:

Reducing portion sizes of high calorie foods

Replacing or substituting high calorie foods with lower calorie foods

Reducing frequency of intake of high calorie foods

If available, patients should be referred to a registered dietitian, nutritionist, or other health care professional educated and certified in nutrition for weight loss to obtain a diet/nutrition plan tailored to their individual needs. Referral to a specific specialist may also increase the likelihood that patients will follow through with an appointment.

In addition, patients should be referred to a behavioral program for weight loss and maintenance to help them adhere to their diet/nutrition goals. Adherence problems plague diet/weight loss attempts, and the behavior change components that are helpful for increasing physical activity apply to reducing calories/weight, as well. Countless workplace, community-based, and commercial diet/weight loss programs are currently available. Physicians may want to select a few local programs to recommend to their patients. As with physical activity, diet/weight loss programs are also available via technology-based tools, such as the Internet and mobile applications.

Referring patients to existing, effective diet/weight loss promotion programs may help them improve their diet and lose or maintain their weight. Programs that incorporate a combination of the following behavioral strategies may be particularly helpful for patients:

Focus of reducing sources of extra calories from beverages and “mindless” eating or any area where the patient thinks it would be easy to reduce.

Focus on the immediate rewards of weight loss (e.g., feeling more energetic, improving self-esteem and body) instead of, or in addition to, the long-term health benefits.

Long-term management.

What helps patients maintain health behavior improvements?

Behavioral research consistently shows that we are generally successful at helping patients stop smoking, lose weight, and increase physical activity. As a field, we are less successful in the long-term maintenance of these health behavior improvements. This can be frustrating for providers and even more frustrating for patients.

The maintenance of behavior change is a key question in current research and there is no simple solution to this problem. That said, we should not give up on attempts to make improvements! Former smokers made an average of seven serious quit attempts before they achieve long-term success. While we do not have answers to the long-term maintenance question, we have hypotheses about why it is so difficult to achieve, as well as data about some predictors of long-term success.

Why is it so difficult?

Smoking, diet, and physical activity improvements all require many behavioral decisions and actions every day, yet one poor choice can turn a day from a “success” to a “failure.” It is difficult to consistently make the best choices when there are so many to make. Contrast dietary choices to the health behavior of getting an annual flu shot. The flu shot only needs to be done once a year. There are fewer behavioral demands for that health behavior, and we aren’t always successful in getting patients to adhere to that recommendation either.

Our environment plays a big role in initiating and maintaining our behavior (both positive and negative). Children are more likely to adopt the health habits of their family. New evidence suggests that our friends may influence our health habits as well. Living close to opportunities for physical activity and recreation is positively associated with our level of physical activity. Some aspects of our environment (e.g., the food we keep in our homes and the types of restaurants we go to) are modifiable, but others are not. Much of our environment encourages sedentary behavior and overeating. However, changing the environment can have a positive impact on health behavior. Smoking policy restrictions have reduced smoking behavior. Being in an environment where others are smoking is a strong predictor of smoking initiation among adolescents. We need to optimize our environments for success.

All three of these health behaviors are also closely related to affect regulation. People smoke, sit on the couch and overeat to deal with stress and regulate negative affect. These poor health habits may effectively reduce negative affect, but their positive effects are only temporary, and of course they cause additional problems. We pay too little attention to the “pros” of these negative health habits; by not addressing them we are potentially less effective at managing change. Directly discussing both the pros and cons of negative health behaviors may enable providers to establish better connections with patients and thus exert greater influence in the realm of behavior change.

We end behavioral interventions too soon. The number of pounds lost is positively related to the length of the intervention. Significant improvements in behavioral interventions regress to baseline levels once the intervention ends. We give our patients antihypertensive medication. Most need to take it for the rest of their lives. We are not surprised when their blood pressure goes up if they stop their medication. The same principle may apply to behavioral interventions. Current research efforts explore “maintenance” or lower intensity interventions that are sustainable for longer periods. For example, ongoing but less frequent contact may increase adherence for a longer period of time, which will increase the odds of permanent positive health behavior adoption. The use of less costly technology to extend the reach of behavioral interventions to mobile platforms is promising as a long-term intervention strategy.

An “all-or-none” mentality is often adopted by patients and physicians alike. This concept describes what happens when patients experience a “slip” or “lapse” in behavior and, rather than forgiving themselves for getting off track but moving on and getting back on track, they feel defeated and give up on their behavior change goals, reverting back to their former behavior (i.e., a complete “relapse”). For example, a smoker making a quit attempt may lapse by smoking one cigarette, then subsequently smoke an entire pack and reconsider his/her decision to quit. Likewise, someone who has been strictly adhering to a diet and physical activity plan may splurge by eating a high-calorie food item and then, rather than return to the weight loss plan, give up, consume an excessive amount of unhealthy foods, and stop exercising all together. Or they may overcompensate by exercising excessively or drastically reducing their caloric intake to unsustainable levels. This overcompensation can be self-defeating and also lead to giving up on behavior change goals. Physicians may fall into a similar trap by not bothering to offer advice or referrals to patients who are not fully committed to a complete lifestyle change, when they may actually make a difference in these individuals’ lives by encouraging them to take small steps toward better health. The overall message is that striving for perfection is unrealistic in health behavior change settings. Patients and physicians are both susceptible to falling into the trap of giving up when they experience a lapse in behavior change. Instead, the focus should be on accepting lapses and moving on from them by returning to original health behavior change goals and not attempting to overcompensate.

IV. Management with Co-Morbidities

Do I counsel them on one or all of the behaviors?

If they want to work in one area and you think they will benefit more from setting a goal in another area: Data suggests that patients can make multiple behavioral changes at once, but each patient is unique. It is more important to ask patients what they are willing to change and encourage them to set a goal in that area. For example, if you have an inactive smoker who is only willing to work on increasing physical activity, set a goal for activity only–even if you think they will benefit more from quitting smoking. Patients are more likely to achieve goals they set. Any behavioral success they have in one area is more likely to spur them on to make improvements in another area. You want their first experience to be a success.

If they want to work in all three areas and you don’t have time to address each one: Identify which area you think would be most helpful for their immediate health needs and tell them your rationale for working in that area. Collaborate with your patient to identify one area to work on and either give them resources to work on the others on their own or make a plan to address the other two at your next scheduled appointments.

If they don’t want to work on ANY area: If you have a patient who needs to improve in one or more areas and is not interested in working on any of them, don’t worry if you can’t convince them. Some patients are not willing to change. What you say in this situation can either turn them off or leave the door open for possible change in the future. The most effective things to focus on are:

Acknowledge that they don’t want to change now, and that is OK.

Your professional opinion about the benefits they might realize IF they were to consider change.

Advise them to think about the possibility of changing in the future.

Tell them you’ll revisit this topic later.

V. Patient Safety and Quality Measures

A. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

Who should do the counseling? Physicians don't have time

Physicians may not have enough time during their appointments to counsel patients about lifestyle issues. Health behavior interventions should come from the medical setting or system and not depend solely on physician counseling. If you are a physician and would like to do more in this area but have limited time, here are some suggestions:

Follow the brief counseling model (see the resources section). You should not spend more than 5 minutes per behavior. If you only have 5 minutes, just counsel on one behavior.

Don’t do any of the counseling, per se. Because of patients’ high level of respect for their provider’s medical opinions and recommendations, giving advice to make behavioral changes is a powerful intervention in itself. Give the patient advice to consider change, give an example of a realistic change, and refer them to someone else for the counseling. If you work with a nurse educator, health promotion department or health psychologist, refer patients to these services. If you don’t have these resources refer patients to other community or online resources.

B. What's the Evidence for specific management and treatment recommendations?